4 Aneurysms 1.5 times the diameter of the adjacent non-aneurysmal vesselUsually begin treatment of AAA in a good risk candidate at 5 cm-endovascular and closer to 5.5 cm for open repairUsually begin treatment of TAA in good risk patient around 6.0 cm for endovascular and 6.5 or greater for open repair

6 Intraoperative-Open All are done under General AnesthesiaAverage time of operation is 2-6 hoursUsual incision is midline for abdominal and thorocoabdominal if also involving thoracic aortaThoracic procedures have lumbar spinal catheter to provide spinal cord protectionEstimated Blood Loss is ccAggressive blood products and fluids are given

10 Postoperative Care-OpenAll open procedures go to the ICU firstStay in the ICU until extubated and can protect their airwayMany require vasoactive dripsHuge fluid shifts take place in the immediate post op period with monitoring of suchPain control is an issueWithout complications, transfer to the floor POD #1 (uncomplicated AAA or ABF) to POD #5-7 (TAAA)

11 Postoperative Care-OpenVital Signs every 8 hoursNeurovascular Checks every 8 hours-this includes all pulses. Note this population has high risk for decreased pulses or limb failure. Contact the team with any changesI and O Record every 8 hours

12 Postoperative Care-OpenOut of the Bed Post op Day #2Ambulate in the Hallway TID Post op Day #3Physical Therapy Consult- Nursing should walk patient if safe to ambulatePT will make recs regarding home care and placement, many will need inpatient rehabAggressive Pulmonary Toliet

13 Postoperative Care-OpenClear liquid diet on POD #4NPO is NPO, no ice chipsAdvance diet to regular day or evening prior to dischargePatients often will have decreased appetite for 6-8 weeks

14 Postoperative Care- OpenMid abdominal Incision with StaplesMay have incisions in the groinVascular Team will take down dressing on POD # 1 and usually leave open to airClean and dryStaples remain in for 2 weeks post op

15 Open Complications Colon ischemiaWound Complications-need to keep clean and dry.Acute Renal Failure-incidence can be as high as 40% of the populationCardiac-All should be on pre op Beta Blockade to be discharged home with same protectionPulmonary-encourage incentive spirometrySpinal cord ischemiaColon ischemia

16 Endovascular Repair of AAA and TAAEVAR techinque was introduced in the 1990s through clinical trialsDecreased Operative RiskThese repairs are beneficial in that they have decreased LOS and recovery time, are able to treat a higher risk patient and most are back to all normal activities within one monthThese devices need to be followed long term and CT’s are obtained at one month, six month, and every year intervals

19 Intraoperative-EndovascularAverage OR time is 2 hoursProcedure is done under MAC anesthetic so patients are awake throughoutEstimated Blood Loss is ccThoracic endografts have lumbar catheters placed for spinal cord protectionMost common complication is difficulty with access

21 Postoperative Care EndovascularEndovascular AAA’s go straight to non monitored regular bedEndovascular TAA’s with spinal drain go to the ICU until drain can be pulledPatients arrive on floor awake and usually with minimal pain

22 Postoperative Care EndovascularVital signs every 4 hours x 2, then q 8 hours-most will run a fever which is post implant syndromeNeurovascular checks every 4 hours x 2, then q 8 hours-this includes all pulses. Let team know of any changesI and O every 8 hoursClear liquids day of surgery and then advance to regular POD #1Out of Bed day of surgeryOne dose of Ancef post operatively

23 Postoperative Care-EndovascularLOS- 1 Day-patients should be ready to go home the morning after surgery. 2 Day LOS if have spinal drainPatients resume home meds and beta blockerFollow-up is in one month with CT scanNo restrictions on activity except no driving while on pain meds

24 Endovascular Repair of Aneurysms-ComplicationsWound-small incisions in groin are at place that can harbor infection. Must keep clean and dry. Must frequently change dressing if drainingCardiac-protected by beta blockade pre and postoperativelyLower extremity ischemiaUrinary Retention

25 Thoracic Outlet Syndrome3 Types- Venous, Arterial, Neurogenic95% is NeurogenicCompression in the Thoracic Outlet largely induced from the scalene muscle relationship to the brachial plexusGoal of operation is to decompress nerves via scalenectomy, lysis of fibrous tissue around nerves, and usually removal of first or cervical rib

26 Thoracic Outlet Syndrome-Post opLow neck incisionFrequent use of a JP drainMajor post op issue is pain controlSome have paravertebral catheter to infuse local anesthetic that are converted to home pump for pain controlRespiratory complications could suggest pneumothorax or hemothorax

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